Hydrosalpinx
A hydrosalpinx is a fallopian tube that
is filled with fluid. Injury to the end of the fallopian tube, the ampulla, and
its delicate fingers, the fimbria, causes the end of the tube to close. Glands
within the tube produce a watery fluid that collects within the tube, producing
a sausage shaped swelling that is characteristic of hydrosalpinx.
Causes
The tubes are prone to injury. The
fimbria are the delicate fingers that extend from the funnel-shaped end of the
fallopian tube to the ovary. The fimbria actively search out the egg after it
is released, or ovulated, and carry the egg to the waiting sperm within the
fallopian tube. The fimbria are lined with delicate cells that contain the
actively moving hair-like cilia, which move the eggs and sperm together. With
injury, not only are the fimbria themselves injured and fused together, but
also the delicate lining cells are lost. Fluid collects within the closed tube.
A normally rich and supportive tubal environment becomes the dead sea of the
hydrosalpinx.
Hydrosalpinx is a result of injury to the tube,
usually from an infection. The classic causes of hydrosalpinx are chlamydia
and gonorrhea, which can run undetected for years, slowly injuring and
destroying the delicate fimbria. IUDs, endometriosis, and abdominal surgery
sometimes are associated with the problem. As a reaction to injury, the body
rushes inflammatory cells into the area, and inflammation and later healing
result in loss of the fimbria and closure of the tube. These infections usually
affect both fallopian tubes, and although a hydrosalpinx can be one-sided, the
other tube on the opposite side is often abnormal. By the time it is detected,
the tubal fluid usually is sterile, and does not contain an active infection.
Not only does a hydrosalpinx cause infertility, it can also
reduce the success rate of fertility treatment, even those treatments that
bypass the fallopian tubes. The blocked tube can communicate with the uterus,
and the fluid in the tube can be expressed out of the tube into the uterus.
This fluid is probably somewhat toxic to early embryo development, and
certainly provides an unfavorable environment. The large volume of the fluid
flow back into the uterus and can produce enough flow that embryos find it
difficult to attach, since they have no ability to move against the tide.
Fertility drugs may cause the fluid to build up in the tube, since the tubes
are responsive to the ovarian hormones produced during fertility drug therapy.
Complications
Hydrosalpinx can be
hazardous during fertility evaluation and treatment, since it is prone to
re-infection. Hysterosalpingogram is a particular problem, since the dye
can inadvertently introduce bacteria into the tubes, and a serious infection
can result. Fertility procedures like insemination and embryo transfer can
cause similar problems. Infection in a hydrosalpinx, salpingitis, can be a
serious surgical emergency and result in hospitalization.
Evaluation
Hydrosalpinx can be
evaluated with several maneuvers: The hysterosalpingogram (HSG) is a
procedure in which dye is placed through the cervix and into the uterus and
fallopian tubes. An X-ray picture then reveals the outline of the uterus and
tubes. A hydrosalpinx appears as a large-sausage-shaped dilation of the tubes.
The folds that are present inside the tube disappear and a flat bulbous shape
is seen. Dye does not spill out of the tube.
Ultrasound uses
sound waves to image the tubes, and is somewhat safer than HSG and more
comfortable. The best view, most of the time, is obtained with a vaginal
ultrasound probe. A normal fallopian tube is usually not visible; a
hydrosalpinx appears as a characteristic sausage-shaped fluid collection
between the ovary and fallopian tube. The wall of the hydrosalpinx is often
thick and flat. Ultrasound provides a quick and painless screen of the pelvic
organs and is an excellent first assessment of the tubes.
Laparoscopy is another means of assessing the tubes, but is
generally used only for treatment and not for assessment. In laparoscopy, a
small television camera is introduced through the belly button. The pelvic
organs can be visualized on a television screen. It has been said that
physicians with expertise at video games excel at the hand-eye coordination
required to perform these procedures! Laparoscopy is the gold standard test for
evaluation, since looking at the fallopian tubes will usually provide the best
view of their anatomy.
Diagnostic tests such as ultrasound and HSG are
not 100% accurate, and can be misleading, sometimes missing significant tubal
disease, and sometimes showing abnormal results when the tubes are actually
quite normal. Laparoscopy usually will confirm the diagnostic tests, but can
show that tubes that were thought to be normal actually have significant
disease, and vice versa. The risks of anesthesia and surgery dictate that
laparoscopy is used for definitive therapy, rather than as a diagnostic test.
Treatment
In vitro fertilization is the ultimate
fertility therapy. The ability to optimize fertilization rates, place
embryos into their correct location, and provide excellent hormonal support to
the early developing embryo have vastly improved success rates over the last
few years. In patients with hydrosalpinx, the fallopian tubes can be bypassed,
since eggs are taken out of the ovary, fertilized in the lab, and transferred
back into the uterus. A hydrosalpinx can be repaired, but with improving
success rates from in vitro fertilization, should it be?
Hydrosalpinx can be repaired in carefully selected cases, but
pregnancy rates remain rather low. Hydrosalpinx can be treated
laparoscopically, a procedure known as neosalpingostomy. In
neosalpingostomy, an incision is made in the end of the hydrosalpinx and the
edges of the incision are folded or flowered back, leaving an open tube.
Unfortunately, the tube often closes back up, and the hydrosalpinx has a high
recurrence rate.
A small hydrosalpinx is the most successfully
repaired. Since pregnancy requires six months to a year after surgery,
younger women with relatively healthy ovaries and eggs, and lots of time, tend
to have the best success rates. Women with a large hydrosalpinx and those in
older age groups do not benefit from surgical repair.
A hydrosalpinx
can have adverse effects on pregnancy rates with in vitro fertilization. As
success rates with in vitro fertilization have
improved dramatically over the past few years, surgical repair of the fallopian
tubes holds less appeal. Indeed, the concerns over re-infection of a
hydrosalpinx and problems with fluid build-up with fertility drug therapy have
raised the stakes for a hydrosalpinx. Removal of a damaged tube reduces the
risk of complications of therapy and improves success rates with
in vitro
fertilization techniques.
Today, most patients with a
hydrosalpinx do not try to repair it. Repair can be done in carefully selected
young patients with minimal damage to their tubes, but should not be attempted
with a large hydrosalpinx in an older woman. In these patients, the tube should
be removed, via laparoscopic salpingectomy. Salpingectomy is an easy
procedure that takes less than an hour. The risks with an experienced surgeon
are low, and the benefits substantial. It is important to choose an experienced
surgeon, since considerations of safety and preservation of the ovarian blood
supply with improvement to later pregnancy rates require judgment and
experience.
Hydrosalpinx is a classic fertility problem that prevents
embryos from reaching the uterus and limits pregnancy rates. It can interfere
with fertility therapy and cause problems for in vitro fertilization.
Fortunately, excellent methods are available to manage the hydrosalpinx. With
the proper expertise, such as that provided by a board-certified reproductive
endocrinologist, success rates are excellent.
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